The pathophysiology of cervical and upper thoracic sympathetic surgery

The pathophysiology of cervical and upper thoracic sympathetic surgery

T₂-T₃ ganglionectomy significantly decreases pulse rate and systolic blood pressure, reduces myocardial oxygen demand, increases left ventricular ejection fraction and prolongs Q-T interval. A certain loss of lung volume and decrease of pulmonary diffusion capacity for CO result from sympathectomy. Histomorphological muscle changes and neuro-histochemical and biochemical effects have also been observed.

M. Hashmonai^{1, 2} and D. Kopelman^{1, 3}

(1)	Faculty of Medicine, Technion—Israel Institute of Technology, Haifa, Israel http://www.springerlink.com/content/jrcm3h5k8pye9yyu/ Volume 13, Supplement 1 / December, 2003 Clinical Autonomic Research

11 of 72 patients were not able to accept the severe compensatory (reflex) sweating

Compensatory hyperhidrosis is the most common complication and the major reason for patient dissatisfaction with the procedure. In a recent report on the complications experienced by 72 patients with palmar hyperhidrosis treated with transthoracic endoscopic sympathectomy, all patients except one complained of compensatory hyperhidrosis, with 41.7% complaining of moderate hyperhidrosis and 43.1% severe! In this study, 11 patients were not able to accept the consequences of compensatory hyperhidrosis, even though their palms had become dry postoperatively. Compensatory hyperhidrosis following sympathectomy can be far more life disrupting than palmar hyperhidrosis in that afflicted individuals may have to change sweat-soaked clothing five or six times per day. Moran states it quite succinctly: Complications related to the surgical approach, such as Horner's syndrome, brachial plexus injuries, pneumothorax, and painful scars may occur, while following sympathectomy compensatory hyperhidrosis is usual and hyperhidrosis may recur.

TREATMENT OF HYPERHIDROSIS

Lewis P. Stolman MD, FRCP(C)

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University of Medicine and Dentistry of New Jersey, New Jersey Medical School; and the Dermatology and Laser Center of Northern New Jersey, Livingston, New Jersey
Dermatologic Clinics
Volume 16 • Number 4 • October 1998

Exam question:

S. Neurogenic Causes (of Hypotension)
10. Post-sympathectomy
http://www.fpnotebook.com/CV/Exam/OrthstcHyptnsn.htm

Medial arterial calcification in 93% of patients who underwent sympathectomy

MAC was noted in both feet in 93 % of patients who had. undergone bilateral lumbar sympathectomy; ...
www.springerlink.com/index/EYA170TL7F6HKGVV.pdf - Similar pages - Note this
by ME Edmonds - 2000 - Cited by 45 - Related articles - All 3 versions

Mechanisms of Skeletal Tracer Uptake

However, if the sympathetic nervous control of the microvasculature is interfered with, vessels that are normally closed now open up (mechanism 5, "recruitment"), and areas of osteoid not
normally exposed to tracer are able to take it up. This "hyperemic" phenomenon is seen after
sympathectomy, stroke, fracture, osteomyelitis, and peripheral neuropathies; the counting rate will be less than twice that over normal bone.

Mechanisms of Skeletal Tracer Uptake
N. David Charkes
Temple University Hospital, Philadelphia, Pennsylvania
J Nucl Med 20: 794-795, 1979

Cardiac Supersensitivity after Sympathectomy

Cardiac postjunctional supersensitivity to beta-agonists after chronic chemical sympathectomy with 6-hydroxydopamine.
Chess-Williams RG, Grassby PF, Culling W, Penny W, Broadley KJ, Sheridan DJ
Naunyn Schmiedebergs Arch Pharmacol 1985; 329:162-6.

Functional and morphological alterations have been reported in cerebral arteries after cervical sympathectomy

Innervation of the human carotid vessels is supplied by the sympathetic system, originating mainly from the superior cervical ganglion, but also from the inferior. Different methods have demonstrated profuse adrenergic innervation of the cerebral blood vessels and regulation of blood flow by the sympathetic system. Functional and morphological alterations have been reported in cerebral arteries after cervical sympathectomy, but vasospasm pathogenesis after subarachnoid haemorrhage remain controversial.

RESULTS

Histological examinations of surgical specimens confirmed ganglion tissues in all cases.

Table 1 shows mean basilar artery diameters for all groups. There were significant statistical differences between groups.

Effects of cervical sympathectomy on vasospasm induced by meningeal haemorrhage in rabbits

Antônio Tadeu de Souza Faleiros^I; Francisco Humberto de Abreu Maffei^II; Luiz Antonio de Lima Resende^III

Sympathectomy for Peripheral Arterial Insufficiency?

SYMPATHECTOMY has been performed frequently on patients with peripheral arterial insufficiency. Clinical results have varied from excellent to very poor, and, in some instances, the insufficiency has been worsened. These varying clinical results have not been completely explained by previous experimental studies.

Effect of Sympathectomy on Blood Flow in Arterial Stenosis *
ALLYN G. MAY, M.D., JAMES A. DE WEESE, M.D., CHARLES G. ROB, M.D.
From the Department of Surgery, University of Rochester School of Medicine and
Dentistry, Rochester 20, New York

sympathectomy improves skin blood flow at the thermoregulatory but not the nutritive level of skin microcirculation

The role of lumbar sympathectomy in the treatment of limb ischemia secondary to arteriosclerosis obliterans has been controversial. Increased temperature and rubor of the skin, which usually follow sympathectomy, have generally been interpreted as indicative of improved nutritive skin blood flow. However, the existence of a (nonnutritive) thermoregulatory level of skin microcirculation makes such an extrapolation questionable.

These results indicate that in case of lower limb ischemia, sympathectomy improves skin blood flow at the thermoregulatory but not the nutritive level of skin microcirculation. This may be related to the fact that the thermoregulatory vessels are mainly sympathetically controlled, whereas the nutritive capillaries are mainly controlled by local (nonneural) factors.

François M.H. van Dielen¹, Harrie A.J.M. Kurvers¹, Ruben Dammers¹, Mirjam G.A. oude Egbrink², Dick W. Slaaf³, Jan H.M. Tordoir¹ and Peter J.E.H.M. Kitslaar¹

(1)	Department of General Surgery, Cardiovascular Research Institute Maastricht and University Hospital Maastricht, PO Box 5800, 6202 AZ Maastricht, The Netherlands, NL

(2)	Department of Physiology, Cardiovascular Research Institute Maastricht, PO Box 616, 6200 MD Maastricht, The Netherlands, NL

(3)	Department of Biophysics, Cardiovascular Research Institute Maastricht, PO Box 616, 6200 MD Maastricht, The Netherlands, NL

Sympathectomy - decreased vascular permeability

The influence of the sympathetic nervous system on capillary permeability was studied in cats. The dye penetration from the blood through the synovial membrane was tested by perfusing the two knee joints, one of which was deprived of its sympathetic nerve supply by unilateral lumbosacral sympathectomy.
Further unpublished experiments seem to support the view that increased blood supply is associated with decreased vascular permeability.

Research in Experimental Medicine D. Engel1

Complications are frequent after ETS

Complications are frequent after surgery for excessive hand sweating. Patient should be informed about the risks

[My paper] G Claes, L Räf

Kirurgiska kliniken, Borås lasarett

Lakartidningen. 1999 Feb 24;96 (8):930-2 10089743

Compensatory Sweating developed in all cases

RESULTS: CS developed in all cases. After completion of ETS, mean blood flow and temperature increased respectively. Significant correlations were found between the range of PCS and increases in palmar temperature (p<0.05) and blood flow (p<0.05). CONCLUSION: Intraoperative monitoring of increases in palmar temperature and blood flow may be useful in patients with primary hyperhidrosis, to predict the range of PCS after ETS.

J Thorac Cardiovasc Surg. 2005 Sep ;53 (9):481-5 16200888

Intraoperative prediction of compensatory sweating for thoracic sympathectomy.

[My paper] Takeo Fujita, Masayuki Mano, Hideyuki Nishi, Nobuyoshi Shimizu

Department of Cancer and Thoracic Surgery, Okayama University Graduate School of Medicine and Dentistry, Okayama, Japan.

Sympathectomy induces novel purinergic sensitivity in sciatic afferents

Acta Pharmacol Sin. 2000 Nov;21(11):1002-4.

Chen Y, Zhang YH, Bie BH, Zhao ZQ. Shanghai Institute of Physiology, Chinese Academy of Sciences, Shanghai 200031, China

Twenty eight percent of the spontaneously active afferent fibers from sciatic nerves in the sympathectomized rats responded to ATP, either with an increase or with a decrease in spontaneous firing. However, none of the fibers from the sciatic nerves in the intact rats was activated by ATP. CONCLUSION: Sympathectomy induces novel purinergic sensitivity in A afferents from sciatic nerve.
http://www.ncbi.nlm.nih.gov/pubmed/11501053

Classification of the surgery by the International Society of Sympathetic Surgeons

Here are the basics of our new classifications:
ESB2 (clamp upper end of T2 only): 2.5%, (in Europe 15%)
Facial blushing, Craniofacial sweating, Some psychic disorders, Rosacea, Vibration disorder (?), Parkinsonism (?)...
ESB3: 2.5%, (in Europe 50%)
Hyperhidrosis Palmaris with Craniofacial sweating, blushing, or any other craniofacial sympathetic disorders
ESB4: 95%, (in Europe 20%)
Hyperhidrosis Palmaris with or without axillary hyperhidrosis (Bromidrosis)
Unilateral ESB: (in Europe 15%)
Social phobia, schizophrenia, sleep disorders, addiction, cardiac arrhythmias

Conclusion: The patients are individuals with individual symptom complexes. There does not seem to exist any clear-cut Hyperhidrosis disease, Blushing disease, nor necessarily any social phobia disease, or schizophrenia disease. All these states are symptom complexes of multiple origin, and should be treated individually along the proposed guidelines.

http://www.hyperhidrosis.com/symposium.htm

Mia: If you are not comfortable undergoing the same surgery that treats heart patients and psychiatric disorders (among many), then you are advised to seek other alternative treatment for your condition.

immunoreactivity

Two days following unilateral section of the cervical vagus nerve, there was a dramatic ipsilateral increase in P2X1, P2X2, and P2X4 receptor
immunoreactivity in the cell soma of vagal efferent neurons in the dorsal vagal motor nucleus, but not in the nucleus ambiguous (72). Following
surgical sympathectomy, 28% of the spontaneously active afferent fibers in sciatic nerve responded to ATP, compared with none in intact rats
(343). After nerve injury, P2X4 receptor expression increased strikingly in hyperactive microglia, but not in neurons or astrocytes, in the
ipsilateral spinal cord; this appears to be associated with tactile allodynia (1731 and see sect. XIB9).

The sympathetic nervous system has been shown to modulate macrophage function (331), and
alterations in T- and B-lymphocyte proliferation and differentiation have been described following chemical sympathectomy (1090). Close
contacts between enteric nerves and lymphocytes in mouse intestinal mucosa and submucosa have been reported (402, 630).

Sympathetic and sensory nerves innervate bone, and sympathectomy modifies bone development and resorption (see Ref. 166). ATP, probably
released as a cotransmitter with NE, regulates Ca2+ metabolism in osteoblast-like bone cells (979). Evidence has been presented to demonstrate a
role for the sympathetic nervous system in controlling bone density via leptin that activates hypothalamic nerves, which in turn activate the
sympathetic nerves that innervate osteoblasts. ATP has been shown to inhibit bone formation by osteoblasts and to stimulate bone resorption by osteoclasts .
Physiology and Pathophysiology of Purinergic Neurotransmission
Geoffrey Burnstock
Autonomic Neuroscience Centre, Royal Free and University College Medical School, London, UnitedKingdom

Reccurrence of symptoms in 17.6% patients!

TS Chiou

Journal of neurosurgery. Spine 2005 Feb

Overall, 88 patients (96.7%) developed compensatory hyperhidrosis, with the mean initial occurrence at 8.2 weeks. The symptoms of compensatory hyperhidrosis progressively worsened to the maximum degree within another 2 weeks after onset (mean 10.3+/-1.83 weeks). In 19 patients (21.6%), symptoms of compensatory hyperhidrosis improved spontaneously within 3 months after sympathectomy (mean 13.3 weeks). Postoperative compensatory hyperhidrosis occurred in 71.4% of patients within the 1st year. Recurrent sweating occurred in only 17.6% of patients. None of these patients required repeated operation. The earliest onset of recurrent sweating was noted at 2 weeks postoperatively by three patients, and the mean initial postoperative reccurrence was 32.7 weeks after surgery.

Skin blood flow, sympathetic vasoconstrictor reflexes and pain before and after surgical sympathectomy

Changes in vascular sensitivity to cold temperature and circulating catecholamines may be responsible for vascular abnormalities. Alternatively, RSD may be associated with an abnormal (side different) reflex pattern of sympathetic vasoconstrictor neurons due to thermoregulatory and emotional stimuli generated in the central nervous system. (3) After sympathectomy, denervation supersensitivity of blood vessels and intense vasomotion may be associated with recurrence of pain in some patients.
BARON R. ⁽¹⁾ ; MAIER C. ⁽²⁾ ;
⁽¹⁾ Klinik für Neurologie, Christian-Albrechts-Universität Kiel, 24105 Kiel, ALLEMAGNE
⁽²⁾ Klinik für Anästhesiologie, Christian-Albrechts-Universität Kiel, 24105 Kiel, ALLEMAGNE
Elsevier, Amsterdam, PAYS-BAS (1975)

Regulation of adrenal angiotensin receptor subtypes: a possible mechanism for sympathectomy-induced adrenal hypertrophy

Regulation of adrenal angiotensin receptor subtypes: a possible mechanism for sympathectomy-induced adrenal hypertrophy.
Qiu, J., Nelson, S.H., Speth, R.C., Wang, D.H. J. Hypertens. (1999)

Hyperalgesia induced in the rat by the amino-terminal octapeptide of nerve growth factor.

Hyperalgesia induced in the rat by the amino-terminal octapeptide of nerve growth factor.
Taiwo, Y.O., Levine, J.D., Burch, R.M., Woo, J.E., Mobley, W.C.
Proc. Natl. Acad. Sci. U.S.A. (1991)

Heterogeneous atrial denervation creates substrate for sustained atrial fibrillation.

Heterogeneous sympathetic atrial denervation with phenol facilitates sustained AF (atrial fibrillation).
Olgin, J.S. et al.

Baker Institute - Cardiac synthesis, processing, and coronary release of enkephalin-related peptides

Chemical sympathectomy produced an increase in total enkephalin content similar to that observed after 2-h control perfusion. This observation suggested that the normal turnover of myocardial enkephalin may depend in part on continued sympathetic influences.

⁽¹⁾ Institut Universitaire de Technologie, Université d'Auvergne, 63172 Aubière, FRANCE
⁽²⁾ Baker Medical Research Institute, Melbourne, Victoria 8008, AUSTRALIE
⁽³⁾ Cardiovascular Research Institute, University of North Texas Health Science Center, Fort Worth, Texas 76107, ETATS-UNIS
⁽⁴⁾ Laboratory of Cardiovascular Science, Gerontology Research Center, National Institute on Aging, National Institutes of Health, Baltimore, Maryland 21224-6825, ETATS-UNIS
YOUNES Antoine ⁽¹⁾ ; PEPE Salvatore ⁽²⁾ ; BARRON Barbara A. ⁽³⁾ ; SPURGEON Harold A. ⁽⁴⁾ ; LAKATTA Edward G. ⁽⁴⁾ ; CAFFREY James L. ⁽³⁾ ;
American journal of physiology. Heart and circulatory physiology ISSN 0363-6135 CODEN AJPPDI

2000, vol. 48, n^o4, pp. H1989-H1998 (41 ref.